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7 Diagnoses Lain-Lain PRINCIPAL DIAGNOSIS The Diagnosis of the Condition Established after Study to be the Chiefly responsible for the Occasioning the Admission of the Patient to the Hospital for Care

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11 OTHER DIAGNOSIS A DIAGNOSIS, other than Principal Diagnosis that describes a condition for which a patient receives treatment or which the physician considers of sufficiencies to warrant inclusion for investigative medical studies

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12 COMPLICATION An Additional Diagnosis that Describes a Condition arising after the beginning of hospital observation and treatment and modifying the course of the patient illness or the medical care required

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14 Komplikasi memiliki arti luas: Apabila: It denotes any condition concurrent with the condition described in the Principal Diagnosis regardless of the time of it’s onset.

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Most Significant Diagnosis The one diagnosis, often but not necessarily the Principal Diagnosis that describes the most important or significant condition of a patient in term of its implications for his/hers health, his/hers medical care, his/hers use of the hospital 15

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16 Asuransi Kesehatan membedakan secara tegas antara: COMPLICATION: Complication is a condition that arises during the hospital stay that prolongs the patient’s LOS by at least ONE day in 75% of the cases COMORBIDITY Comorbidity is a pre-existing condition that will, because or it’s present with a specific principal diagnosis cause  an increase in the patient’s LOS by at least ONE day in 75% of the cases.

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19 CASEMIX-ADJUSTED =Statistics where the effects of variations in case-mix have been taken into account.

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20 CASEMIX-ADJUSTED COST PER INPATIENT = The total cost of provision of inpatient care, divided by total inpatients treated; and adjusted to take account of the actual mix of patients treated and differences in the mean costs of casemix classes

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21 CASEMIX-BASED FUNDING = A method of funding similar (and in some circumstances identical) to output-based funding. Involves funding of the health care products of health care delivery units, where the products are categorized using CASEMIX CLASSIFICATION.

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22 TASK WHERE PATIENT CLASSIFCATION CAN HELP Deciding whether re-admission rates are abnormally high Deciding whether too many or too few pathology tests are being ordered Finding and fixing problems of poor outcome for rehabilitation patients Designing benefits structures in private insurance Deciding how resources should be allocated between public hospitals Allocating funds between hospital departments Planning bed and staff numbers for new hospital Investigating whether the nurse staffing mix needs to be changed.

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23 USES OF PATIENT CLASSIFICATION Patient classifications are useful because they help us to find differences in: - outcome, - quality, or - cost of care. By understanding the differences, health care professional find opportunities to make health care more effective. Casemix seeks to improve classification of patients care episodes and put them to better use.

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24 3 (three) FEATURES OF CASEMIX (1)Clinical meaning (patients in the same class should have clinical similarities) The episodes in a class should involve similar kinds of; -presenting problems, -treatment methods and -outcomes. It is not sufficient merely to ensure that each class contains episodes which are similar in cost. Casemix is designed to ensure every class makes sense to clinicians.

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25 CLASS A class defined as “patients who were in hospital for over 20 days” might contain episodes which are similar in terms of resource used, but it has little clinical meaning, because there are many different reasons for long stays (major trauma, need for rehabilitation, social problems which delay discharge)

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26 FEATURES OF CASEMIX (CONT.-1) Resource use homogeneity (patients in the same class should cost roughly the same treat). Classes is designed in such a way that episodes which required similar levels of resource are assigned to the same class. (Is defining classes by surgical and medical is better than forming them by age?)

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27 FEATURES OF CASEMIX (CONT.-2) In the real world, many more patient care episodes and many more attributes, (such as diagnoses, functional abilities, and type of admission) must be considered.  apply statistical methods to find and evaluate all the options  Finding rules which define the classes in such a way that episodes in the same class are similar in terms of resource use.

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28 FEATURES OF CASEMIX (Cont.-3) (3)The right number of classes (neither too few or too many) (optimal numbers of classes) It is difficult to know how many classes of patient care episodes there should be. Too many classes will have too few observations to allow conclusions to be drawn. Then it would be impossible to know whether a hospital is really different, or whether analyses are merely showing the kind of variability which is normal in small samples.

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29 FEATURES OF CASEMIX (Cont.-4) On the other hand there should not be too few classes. If large numbers of dissimilar cases are placed in the same class, real differences between doctors, nurses, hospitals and so on will be concealed and clinical meaning will be lost.  A compromise is needed.  A statistical methode is needed.

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32 CASEMIX - DRGs The size of database depends on the number of patients care episodes which are to be analyzed using the classification.

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33 CASEMIX - DRGs (Lanjutan-1) The extended use: a classification with few classes might be ideal for some strategic management purposes, but less so for a private hospital which is dependent for its financial survival on very precise description of it casemix.

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34 CASEMIX - DRGs (Lanjutan-2) Many assumed there is only one casemix classification. DRGs is the most used casemix classification in the last decade  the use of DRGs for resource allocation deserves special attention.  trend is towards a wider range of uses of many more casemix classifications

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35 A MORE PRECISE STATEMENT ABOUT CASEMIX CASEMIX IS part of a science approach to producing good information about health care IT FOCUSES ON building useful classifications of patients care episodes ANDmaking good use of patient care classifications to manage health care.

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36 A MORE PRECISE STATEMENT ABOUT CASEMIX (Lanjutan) Casemix has to be complicated if it is to help resolve real problems. There would be little sense in simplifying casemix ideas and tools so much that they would no longer be relevant to the real world. Their complexity merely reflects the nature of health care, and if used properly they make the world less, not more, confusing.

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42 DRGs ( Diagnosis-Related Groups) Ini adalah klasifikasi pasien rawat. DRGs are designed to catagorise acute inpatient episodes, but CASEMIX classifications have been developed for other kinds of episodes: -outpatients, -nursing home care.

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43 DRG (Lanjutan-1) (1)The first step involves looking at the principle diagnosis = the diagnosis or condition established after study to be chiefly responsible for the patient’s admission to hospital. (2)The significant procedure performed and check the kind of procedure.

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45 AN- Casemix Dictionary The Australian Casemix Dictionary (Department of Human Services and Health): Diagnoses clusters: A classification system developed in the early 1970s. Which only made use of diagnoses. (AVGs = Ambulatory Visit Groups)

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46 AHIMA & AN-DRG Diagnosis chiefly responsible for services provided (out patient) = The diagnosis, condition, problem, or reason for encounter/visit that is chiefly responsible for the services provided. If a definitive diagnosis has not been established at the end of the visit/encounter, the condition s hould be recorded to the highest documented level of specificity (such as symptoms, signs, abnormal test results, or other reason for visit).

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48 AN-DRG 1.PDX is used to assign the episode of care to one of 23 Major Diagnostic Categories (MDCs) MDCs correspond generally to the main organ systems of the body. The following specific variables are exceptions: - Age less than 29 days - Principal diagnosis which is a specific neonatal disorders -Principal or secondary diagnosis of HIV -Liver transplant -Bone marrow transplant -Principal diagnosis of multiple trauma - Tracheostomy procedure.

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49 AN – DRGs (Lanjutan-1) 2.Medical or surgical partition according to whether a significant operating room (OR) procedure has been performed. It is to be noted that not all procedures are considered significant OR procedures. 3.Sub grouping based on the precise surgical procedure performed or, for medical patients, the precise condition designated as the principal diagnosis.

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50 AN – DRGs (Lanjutan-2) 4.Final assignment to a DRG is usually made by age or the existence of a complicating diagnosis and/or comorbidity (CC)* A substantial complication or comorbidity (CC) is defined as a condition that because of its presence with a specific principal diagnosis, would cause an increased in the length of stay by at least one day.

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51 PRINCIPAL DIAGNOSIS The diagnosis or condition established after study to be chiefly responsible for occasioning the patient’s admission to hospital. (AN-standard definition. One of the two most important variables used to define AN-DRG classes)

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53 PRINCIPAL PROCEDURE The procedure performed for definitive treatment rather than for diagnostic or exploratory purposes. In the context of assignment to an AN-DRG class, selection of one procedures as principal is not necessary. PROCEDURE A therapeutic intervention. Procedures are coded using ICD-9-CM. One of thetwo most important variables used to define DRG classes.

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54 PROCEDURE HIERARCHIES List of procedures in order of their relative costliness. Assignment to an AN-DRG is on the basis of the highest ranking procedure only, where two or more were undertaken. Ranking is determined by the computer software (the Grouper). PROCEDURE REVIEW A type of utilization review which involves assessing the patient’s need for diagnostic and therapeutic procedures.

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55 PROSPECTIVE PAYMENT SYSTEM PPS A type of output-based funding formula, whereby health care providers (usually hospitals) receive predetermined payments for each episode of care defined by casemix classes. (Usually DRGs) The term was first used for US Medicare’s DRG-based payment system for hospitals. PATIENT CLASSIFICATION SYSTEM (Private Hospital) A simple casemix classification for inpatient episodes which is used to bill for all services excepting critical care and operating rooms.

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